Introduction:
For over 25 years, Tactical Combat Casualty Care (TCCC) guidelines have been described in the Journal of Special Operation Medicine, Military Medicine, Wilderness & Environmental Medicine, and more recently in the Wilderness Medical Magazine (WMM). Tactical Combat Casualty Care serves as the Department of Defense (DoD) standard of care for non-medical and medical first responders for emergent care on the battlefield. Subsequent to the establishment of TCCC Guidelines in 1997, the Prolonged Casualty Care (PCC) (formerly called Prolonged Field Care) guidelines were implemented in 2013. These guidelines are now standardized throughout DoD for austere battlefield casualty care beyond the Golden Hour.
Prolonged Casualty Care clinical practice guidelines (CPGs) list the skills, abilities, and best practices for battlefield casualty management that were specifically developed for patient care during a prolonged period of time in austere or remote settings. Although PCC may not be as well known to WMM readership, they are a set of CPGs that have relevance to wilderness medicine. Therefore, our intent is to provide: 1) a brief overview of PCC based on the most recent updated CPG, December 2021; and 2) provide one example of a PCC best practices format by posting the hyperthermia CPG; and 3) discuss the relevance of PCC clinical practice guidelines for prolonged care to wilderness medicine.
Background:
Prolonged Casualty Care emerged as an area of focus for US military Special Operations Forces medical experts. Prolonged Casualty Care Guidelines focuses on providing medical care to military forces often deployed in remote and austere locations far from the casualty evacuation chain. These guidelines were developed and maintained by the PCC Working Group under the Defense Committee on Trauma to provide subject matter expertise supporting the Joint Trauma System mission. Recently published is a joint consensus statement by the Committee on Tactical Combat Casualty Care and the PCC Working Group that states that “the PCC Guidelines are the standard of care for developing and sustaining Department of Defense programs required to enhance confidence, interoperability, and common trust among all PCC adept personnel, but first, TCCC and how it relates to PCC”. The current PCC Guidelines can be obtained at either the Joint Trauma Systems website or by Remley MA et al, Journal of Special Operations Medicine, 2021.
PCC Considerations After TCCC Intervention:
The PCC mnemonic “MARC2H3-PAWS-L” (see Table 1) helps guide users through what to consider after all TCCC interventions have been effectively performed:
1. Address and reassess all immediate life threats and interventions, per current TCCC guidelines, before moving onto PCC considerations.
2. Re-triage casualties and resources, as required, using appropriate triage decision tools.
3. Confirm notifications of the incident, telemedicine, and requests for evacuation were sent and received through the proper channels.
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Table 1. The Definition of the Prolonged Casualty Care Mnemonic
MARC2 H3-PAWS-L
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M - Massive Hemorrhage/MASCAL (mass casualty)
A - Airway
R - Respirations
C - Circulation
C - Communication
H - Hypothermia/Hyperthermia
H - Head Injury
P - Pain Control
A - Antibiotics
W - Wounds (+ Nursing/Burns)
S - Splints
L - Logistics
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The PCC Working Group states that the primary goal is to get out of PCC; and they state that the operational and medical planning should avoid categorizing PCC as the primary medical support capability or control factor during deliberate risk assessment. However, effective medical planning should always consider PCC as a contingency.
Principles of PCC
The principles and strategies of providing effective prolonged casualty care are meant to help organize critical information into a clear proactive plan. The following steps (see Figure 1) can be implemented in any austere environment:
Figure 1. Principles of Prolonged Casualty Care.
The PCC Working Group provides the following checklist that is meant to emphasize some of the most important principles in efficient care of the critically ill patient as presented in these CPGs.
1. Perform initial lifesaving care using TCCC guidelines and continue resuscitation.
The foundation of good PCC is mastery of TCCC and a strong foundation in clinical medicine.
2. Delineate roles and responsibilities, including naming a team leader.
A leader should be appointed who will manage the larger clinical picture while assistants focus on attention intensive tasks.
3. Perform comprehensive physical exam and detailed history with problem list and care plan.
After initial care and stabilization of a trauma or medical patient, a detailed physical exam and history should be performed for the purpose of completing a comprehensive problem list and corresponding care plan.
4. Record and trend vital signs.
Vital signs trending should be done with the earliest set of vital signs taken and continued at regular intervals so that the baseline values can be compared to present reality on a dedicated trending chart.
5. Perform a teleconsultation.
As soon as is feasible, the medic should prepare a teleconsultation by either filling out a preformatted script or by writing down their concerns along with the latest patient information.
6. Create a nursing care plan.
Nursing care and environmental considerations should be addressed early to limit any provider induced iatrogenic injury.
7. Implement team wake, rest, chow plan.
The medic and each of their first responders should make all efforts to take care of each other by insisting on short breaks for rest, food, and mental decompression.
8. Anticipate resupply and electrical issues.
9. Perform periodic mini rounds assessments.
Stepping back from the immediate care of the patient periodically and re-engaging with a mini patient round and review of systems can allow the medic to recognize changes in the condition of the patient and reprioritize interventions.
- Is the patient stable or unstable?
- Is the patient sick or not sick?
- Is the patient getting better or getting worse?
- How is this assessment different from the last assessment?
10. Obtain and interpret lab studies.
When available, labs may be used to augment these trends and physical exam findings to confirm or rule out probable diagnoses.
11. Perform necessary surgical procedures.
The decision to perform invasive and surgical interventions should consider both risks and benefits to the patient’s overall outcome and not merely the immediate goal.
12. Prepare for transportation or evacuation care.
If the medic is caring for the patient over a long tactical move or strategic evacuation, they should be prepared with ample drugs, fluids, supplies and be ready for all contingencies in flight.
13. Prepare documentation for patient handover.
The preparation for transportation and evacuation care should begin immediately upon assuming care for the patient and should include hasty and detailed evacuation requests up both the medical and operational channels with the goal of getting the patient to the proper role of care as soon as possible.
Where appropriate, a minimum-better-best format is included for situations in which the operational reality precludes optimal care for a given scenario:
- Minimum: This is the minimum level of care which should be delivered for a specified level of capability.
- Better: When available or practical, this includes treatment strategies or adjuncts that improve outcomes while still not considered the standard of care.
- Best: This is the optimal medical for a given scenario based on the level of medical expertise of the provider
In the PCC hyperthermia CPG (see Figure 2), each tier of military medical provider states the expectations of prehospital care, based on TCCC's role-based standard of care, are included within each section:
- Tier 1: This is the basic medical knowledge for all service-members (ASM).
- Tier 2: Those who have been through approved Combat Life Saver (CLS) training are expected to be able to meet the standards at this level of care.
- Tier 3: (Combat Medics/Corpsmen [CMC]): Those who are trained medics/corpsmen are expected to meet the medical standards for this tier.
- Tier 4: (Combat Paramedic/Provider [CPP]): This is the highest level of prehospital capability and will have a significantly expanded scope of practice.
The following is one example using hyperthermia taken from the PCC Clinical Practice Guideline with the format presented above for each care provider using the minimum-better-best format. This format is consistent for all PCC guidelines.
Figure 2. Prolonged Casualty Care Guidelines for Hyperthermia.
Implication for the Wilderness Provider
The PCC guidelines are a good model to follow for extended care in the wilderness. Currently, there is a course to consider called the Austere Emergency Care Course (AECC). The AECC is a prolonged field care course based on 10 years of knowledge gained from our original military Prolonged Field Care Working Group and Ragged Edge Solutions’ experience and background in training military special operations to operate around the world without traditional medical support. It is a 4-day course designed for the non-military responder, clinician or provider who may have to manage the care of patients in austere and resource limited environments for longer than desired. It is ideal for teams operating in any remote locale where quick medevacs are not readily available such as Humanitarian Assistance/Disaster Relief, Search and Rescue, Expedition, Arctic, Maritime, Topical, Off-Shore, or even Rural EMS crews who have long transport times due to distance or weather. Other PCC trainer resources are found on the Deployment Medicine website. Note: you must create an account to access these PCC and TCCC resources.